The Medical Record
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| Functions of a Medical Record | - documents the results of treatment and the patient's progress
- serves as a legal document
- efficient and effective method for communicating in the medical office
🗑
|
||||
| What does HIPAA stand for? What is its purpose? | Health Insurance Portability and Accountability Act
-To provide patients with a better control over the use and disclosure of their health information.
🗑
|
||||
| General categories of information that are included on a patient registration record | - Patient's demographic
- Billing information
🗑
|
||||
| Uses of the health history | - To determine the patient's general state of health
- To arrive at a diagnosis and to prescribe treatment
- To document any changes in a patient's state of health
🗑
|
||||
| Categories of medication that may be included in a medication record | - Prescription medications
- Over the counter medications
- Medications administered at the Medical Office
🗑
|
||||
| Components of a Medical Record | - Administrative/clinical documents
- Laboratory
- Diagnostic procedures
- Therapeutic services
- Hospital documents
- Consent documents
🗑
|
||||
| Administrative Documents | - Registration forms
- Correspondence
🗑
|
||||
| Clinical Documents | - Health history
- Physical examination
- Progress notes
- Medication and immunization records
- Consultation/home health reports
🗑
|
||||
| Laboratory Documents | - Hematology
- Chemistry
- Serology
- Urinalysis
- Microbiology
- Cytology
- Parasiology
🗑
|
||||
| Diagnostic Procedures | - Holter monitor reports
- Sigmoidoscopy
- Colonoscopy
- Spirometry
- Imaging (x-rays, CT scans, MRI)
- EKG's
🗑
|
||||
| Therapeutic Services | - Physical therapy
- Occupational therapy
- Speech therapy
🗑
|
||||
| Hospital Documents | - History and physical
- Operative report
- Discharge Summary
- Pathology report
- ER report
🗑
|
||||
| Consent Documents | - Consent to treatment
- Consent to release medical reports
🗑
|
||||
| Medical Record preparation (supplies) | - File folders
- Labels
- Chart dividers
🗑
|
||||
| Charting (progress notes) - What do we chart? | - Patient symptoms
- Procedures
- Administration of medications
- Specimen collection
- Results of lab tests
- Diagnostic procedures
- Instructions given to a patient regarding care
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
Rachel_m
Popular Medical sets